Difficult neonatal ileostomy/fistula

[Jaiden]

Hello,

I'm new here but I was hoping someone might be able to help. I am newly qualified and work on a NICU which mainly deals with surgical neonates eg. NEC, Gastroschisis, Exomphalos, Oesophageal Atresia etc.

The neonate in question is a 32 weeker who is now 3 months old. He contracted NEC which failed to respond to medical management and he went to theatre for a laparotomy. He now has an ileostomy and a mucus fistula. Both stomas have herniated so are 'mushroomed' at the bottom and the fistula is badly prolapsed. His umbilicus is also herniated. This infant is about 3.5kg but has a very small abdomen as you would expect. We are having major problems applying the stoma bags as he needs one on both the ileostomy and the fistula. Due to the bad prolapse it is almost impossible to get a bag over the fistula (and it gets worse as he screams) and when you do the outside sticky part is barely adhered to the skin as it is too small. Child's mum has been applying duoderm around the edges of both bags and up over the ridge in between the bags to try and stop leaks. The bags are needing changing twice a day at least and the skin is starting to break down. We've tried putting 'doughnuts' around the base of the stoma but the main problem is getting the bags on. Any wise words?

Sorry if its all very ineloquent, I'm very new to stoma care as didn't get much experience of it as a student, and just want to find a way to make things better for this baby. Our stoma nurse is also stumped and the surgeons don't want to know!

Charlotte x

[nicurn-jenn]

Charlotte,

This patient probably no longeris having this issue...i hope, however, I work with ostomies everyday at work. We use different things to keep the bags on and treat the skin. I always apply No-sting and a light layer of stomahesive powder to skin breakdown or rashes. It makes a light protective layer and its amazing how soon you start seeing improvement. I also never let a bag go more than 24hrs on skin that has some breakdown and no more than 48hrs at all. This has improved incidences of skin issues on the unit.

For the baby mentioned above I probably would have mixed stomahesive some type cream you might use for diaper rashes (butt cream). Making a paste to use with every assessment. Cleanse the area really well without rubbing. apply No-sting then stomahesive powder to make a crust. If the two are alternated a few times a nice crust develops. Then get dirty by using a gloved finger to apply the paste that was made earlier. cover with a 4x4 and apply a diaper over the "mess" you've just created to cover the belly. Put a regular diaper on the baby as usual (might have to use a larger size for now to fit over the dressings). Repeat this process with assessments. You will see improvements in the skin. This baby also needs some pain control. That rawness around his ostomies is very painful. Once the skin is in better shape then you can begin to bag the osomy/fistula again.

I know its a long post but I have seen bad raw skin in our unit just from lack of knowledge on how to handle the skin issues. We've gotten much better in our unit. But there is always a new issue to conquer.

I hope this helps a bit to anyone out there with similar issues :nuke: